• Users Online: 156
  • Home
  • Print this page
  • Email this page
Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contacts Login 


 
 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 13  |  Issue : 1  |  Page : 4-8

A comparative study of equipotent doses of intrathecal clonidine and dexmedetomidine on characteristics of bupivacaine spinal anesthesia


Department of Anesthesia, JNMC, Sawangi (M) Wardha, Maharashtra, India

Date of Web Publication10-Sep-2018

Correspondence Address:
Dr. Rahul Rajan
Department of Anesthesia, JNMC, Sawangi (M) Wardha, Maharashtra
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdmimsu.jdmimsu_59_18

Rights and Permissions
  Abstract 


Background: We compared the onset and duration of sensory block, onset and duration duration of motor block, analgesia time, and adverse effects along with the hemodynamic changes, following intrathecal administration of dexmedetomidine or clonidine with bupivacaine. Materials and Methods: A total of 120 ASA Grade I or II patients, aged between 18 and 60 years, were enrolled in the study. The patients were randomly allocated to three equal groups: Group B received hyperbaric bupivacaine (0.5%) 15 mg with normal saline as a placebo, Group D received bupivacaine with 5 μg of dexmedetomidine, and Group C received bupivacaine with 50 μg of clonidine. All solutions were made up to 3.5 ml with addition of normal saline and injected at L3–L4 using a 25G spinal needle. The onset and duration of sensory and motor blockade and the sensory and motor regression times were recorded and the sedation level was also calculated. Hemodynamic changes and time to use first rescue analgesia, diclofenac sodium 75 mg IM, were also recorded. In postanesthesia care unit, pain scores were recorded using visual analog scale. Analysis of variance test was used to compare the quantitative variables in between the three groups which were independent of each other. Chi-square test was used to compare categorical variables. All the data were analyzed using SPSS (SPSS Inc., Chicago, IL)versus 17. P < 0.05 was considered statistically significant. Results: There was no significant difference in patients' demographics or duration of surgery. The time to onset of sensory block and motor block was early in Group D and Group C as compared to Group B. Duration of sensory and motor blockade was prolonged in Groups C and D, compared with Group B. Two-segment regression time was prolonged in Group C and Group D as compared to Group B. Intraoperative hemodynamics and level of sedation were clinically not significant in all the groups. Conclusion: The addition of clonidine or dexmedetomidine to intrathecal bupivacaine prolongs the motor and sensory block and postoperative analgesia when compared to bupivacaine alone with preserved hemodynamic stability in lower abdominal and lower limb surgeries.

Keywords: Dexmedetomidine, equipotent doses, intrathecal clonidine


How to cite this article:
Rajan R, Gosavi S N, Dhakate V, Ninave S. A comparative study of equipotent doses of intrathecal clonidine and dexmedetomidine on characteristics of bupivacaine spinal anesthesia. J Datta Meghe Inst Med Sci Univ 2018;13:4-8

How to cite this URL:
Rajan R, Gosavi S N, Dhakate V, Ninave S. A comparative study of equipotent doses of intrathecal clonidine and dexmedetomidine on characteristics of bupivacaine spinal anesthesia. J Datta Meghe Inst Med Sci Univ [serial online] 2018 [cited 2018 Sep 26];13:4-8. Available from: http://www.journaldmims.com/text.asp?2018/13/1/4/240904




  Introduction Top


Spinal anesthesia is the most preferred technique for lower abdominal and lower limb surgeries. It minimizes or completely avoids the problem associated with general anesthesia such as airway management.

Centrally acting α-2 adrenoceptor agonists such as clonidine and dexmedetomidine have been used as adjuvants to local anesthetic agents because of their sedative, analgesic, and hemodynamic stabilizing effect. They have been found to prolong the duration of spinal block following intrathecal administration.

Hence, we have undertaken this study to evaluate and compare the effects of clonidine and dexmedetomidine as adjuvants to intrathecal hyperbaric bupivacaine in patients scheduled for elective lower abdominal and lower limb surgeries.

Aims and objectives

To compare the following characteristics following bupivacaine spinal anesthesia with either clonidine or dexmedetomidine:

  1. Onset and duration of sensory block
  2. Onset and duration of motor block
  3. Hemodynamic changes intraoperatively
  4. Level of sedation intraoperatively
  5. Any side effects associated with these two drugs
  6. Postoperative pain relief.



  Materials and Methods Top


This study was carried out in the Department of Anesthesiology, Acharya Vinoba Bhave Rural Hospital, annexed to Jawaharlal Nehru Medical College, Sawangi (Meghe), Wardha, during the period from October 2014 to June 2016.

The study comprises of 120 patients. They were randomly allocated to one of the three groups of 40 each.

  • Group B: 0.5% bupivacaine 15 mg + 0.5 ml normal saline (3.5 ml)
  • Group C: 0.5% bupivacaine 15 mg + 50 μg clonidine (3.5 ml)
  • Group D: 0.5% bupivacaine 15 mg + 5 μg dexmedetomidine (3.5 ml).


Normal saline was added in all three groups to make 3.5 ml of total volume.

Clearance from the Institutional Ethical Committee was taken before undertaking the study.

Type of study

This was a prospective, double-blind observational study.

Study drugs

  • Group B: 0.5% bupivacaine 15 mg + 0.5 ml normal saline (3.5 ml)
  • Group C: 0.5% bupivacaine 15 mg + 50 μg clonidine (3.5 ml)
  • Group D: 0.5% bupivacaine 15 mg + 5 μg dexmedetomidine (3.5 ml).


After the spinal block, intraoperatively, the following parameters were observed and recorded.

Level of sensory block was assessed by pinprick and motor block by Bromage scale. Surgery was allowed to start as soon as sensory block reached the required level of anesthesia for concerned surgery and the total duration of sensory block was noted.

Level and total duration of motor block were noted.

Two-segment regression time was noted.

Intraoperative level of sedation was noted.

Total duration of analgesia was noted.

Postoperative visual analog scale (VAS) score was noted.


  Observation and Results Top


The mean time of onset of sensory blockade in Group B (control group) is 2.85 ± 0.66 min, in Group C (clonidine group) is 1.47 ± 0.5 min, and in Group D (dexmedetomidine group) is 1.17 ± 0.38 min. There is a statistically highly significant difference when Group B was compared with Group C and with Group D (P = 0.0001), and there is statistically significant difference between Group C and Group D (P = 0.034).

Twelve out of 40 patients in Group B (control group), 7 out of 40 patients in Group C (clonidine group), and 16 out of 40 patients in Group D (dexmedetomidine group) had T4 level of sensory blockade.

Three out of 40 patients in Group B, 0 out of 40 patients in Group C and 0 out of 40 patients in Group D had T5 level of sensory blockade.

Twenty-five out of 40 patients in Group B, 33 out of 40 patients in Group C, and 24 out of 40 patients in Group D had T6 level of sensory blockade.

There is no statistically significant difference between the groups (P = 0.27).

The mean time taken for the onset of motor blockade is 4.02 ± 0.69 min in Group B (control group), 1.62 ± 0.49 min in Group C (clonidine group), and in Group D (dexmedetomidine group) is 1.02 ± 0.15 min. There is a statistically highly significant difference between Group B and Group C and between Group B and Group D (P = 0.0001); there is also statistically significant difference between Group C and Group D.

The sedation score was 0 in 25 patients, 1 in 15 patients, and 2 in 0 patients in Group B (control group).

The sedation score was 0 in 24 patients, 1 in 13 patients, and 2 in 3 patients in Group C (clonidine group).

The sedation score was 0 in 24 patients, 1 in 15 patients, and 2 in 1 patient in Group D (dexmedetomidine group).

There is statistically no significant difference between groups (P = 0.44).

The mean time taken for regression of sensory block by two segments is 79.25 ± 9.44 min in Group B (control group), 137.00 ± 10.42 min in Group C (clonidine group), and 158.62 ± 11.37 min in Group D (dexmedetomidine group). There is a statistically significant difference between Group B and Group C and between Group B and Group D and also there is significant difference between Group C and Group D.

We found that mean duration of analgesia was 200.87 ± 69.87 min in Group B (control group), 420.75 ± 64.24 min in Group C (clonidine group), and 522.20 ± 18.84 min in Group D (dexmedetomidine group).

There was statistically significant difference between Group B versus Group C and Group B versus Group D. And also, there was significant difference between Group C versus Group D.

We found that mean duration of motor block was 159.12 ± 57.17 min in Group B (control group), 277.37 ± 22.50 min in Group C (clonidine group), and 303.50 ± 33.47 min in Group D (dexmedetomidine group).

There was statistically significant difference between Group B versus Group C and Group B versus Group D. And also, there was significant difference between Group C versus Group D.

We found that mean VAS score was 1.53 ± 0.78 at 1 h in Group B and 0.0 in clonidine and dexmed group. At 2 h, mean VAS score was 2.50 ± 0.82 in Group B, 0.45 ± 0.68 in Group C, and 0.0 in Group D. At 3 and 4 h, mean VAS score was significantly lower in Group C (0.95 ± 0.88, 1.35 ± 0.86) and Group D (0.13 ± 0.33, 0.45 ± 0.78) as compared to Group B (3.50 ± 0.60, 4.88 ± 0.94) [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8].
Figure 1: Sensory onset (minutes) and SD

Click here to view
Figure 2: Sensory Level

Click here to view
Figure 3: Motor onset (min) and SD

Click here to view
Figure 4: Sedation Score

Click here to view
Figure 5: Sensory regression by two segments (mins) and SD

Click here to view
Figure 6: Analgesia

Click here to view
Figure 7: Motor Blockade (mins) and SD

Click here to view
Figure 8: Postoperative pain

Click here to view



  Discussion Top


Alleviation of pain has been the major goal of anesthesia. With the technical skill and pharmacological knowledge, anesthesiologists are in an ideal position to treat pain during the intraoperative and postoperative period. The aim of good postoperative analgesia is to produce a long-lasting, continuous effective analgesia with minimum side effects.

Hence, an intrathecal additive to these local anesthetics forms a reliable and reproducible method to prolong the duration of anesthesia and provide prolonged postoperative analgesia. This technique being simple and less cumbersome has gained a wide acceptance.

In our study, the intrathecal dose of clonidine and dexmedetomidine selected was based on previous human studies wherein no neurotoxic effects have been observed. Kanazi et al. and Al-Ghanem et al. found that dexmedetomidine and clonidine added to bupivacaine produced a similar prolongation in the duration of the motor and sensory block, with preservation of hemodynamic stability.

Time of onset of sensory block was comparable to the studies conducted by Kanazi et al., Saxena et al., and Shukla et al.

In studies conducted by Kanazi et al., the median and range of peak sensory level reached were T6 (T4–T10) in Group B, T6.5 (T3–T9) in Group C, and T6 (T2–T10) in Group D without significant differences between the groups (P > 0.3).

Our study is also comparable to studies conducted by Gupta et al. and Strebel et al.

In our study, the mean time for onset of motor block is 4.02 ± 0.69 min in control group, 1.62 ± 0.49 min in clonidine Group, and 1.02 ± 0.15 min in dexmedetomidine group. our study is in accordance to Saxena et al. and Shukla et al.

In our study, the time taken for regression of sensory block by two segments is 79.25 ± 9.44 min in the control group (Group B), 137.00 ± 10.42 min in the clonidine group (Group C), and 158.62 ± 11.37 min in dexmedetomidine group (Group D). Thus, we observed that the two-segment regression time is significantly prolonged in clonidine and dexmedetomidine groups than in control group. Our study concurs with the study conducted by Kanazi et al., Mahendru et al., and Om Prakash et al.

The mean duration of analgesia in our study is 200.87 ± 69.87 min in control group, 420.75 ± 64.24 min in clonidine group, and 522.20 ± 18.84 min in dexmedetomidine group. There is a statistically highly significant increase in the duration of analgesia in dexmedetomidine and clonidine group compared to the control group. Our study is in accordance to Gupta et al., Chhabra et al., and Abdelhamid et al.

In our study, the mean duration of motor blockade was 159.12 ± 57.17 min in control group, 277.37 ± 22.50 min in clonidine group, and 303.50 ± 33.47 min in dexmedetomidine group. There is a statistically highly significant increase in the duration of motor blockade in dexmedetomidine group and clonidine group compared to the control group. Our study concurs with Kanazi et al., Al-Ghanem et al., and Joshi et al.

In our study, we found that the mean VAS score was 1.53 ± 0.78 at 1 h in Group B and 0.0 in clonidine and dexmedetomidine group. At 2 h, mean VAS score was 2.50 ± 0.82 in Group B, 0.45 ± 0.68 in Group C, and 0.0 in Group D. At 3 and 4 h, mean VAS score was significantly lower in Group C (0.95 ± 0.88, 1.35 ± 0.86) and Group D (0.13 ± 0.33, 0.45 ± 0.78) as compared to Group B (3.50 ± 0.60, 4.88 ± 0.94). Our study is comparable to studies conducted by Chandrashekharappa et al. and Abdelhamid et al.

Hemodynamics and level of sedation intraoperatively were clinically nonsignificant which is in accordance to most of studies conducted.

In our study, these side effects were not significant maybe because of small dose of intrathecal clonidine and dexmedetomidine used, which is in accordance to studies conducted by Kanazi et al. and Al-Ghanem et al.[1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29]


  Conclusion Top


From our study, it can be concluded that equipotent doses of intrathecal dexmedetomidine in the dose of 5 μg or intrathecal clonidine in the dose of 50 μg along with 3 ml bupivacaine 0.5% heavy in patients of lower abdominal surgeries and lower limb surgeries:

  • Decrease the onset time for sensory blockade
  • Decrease the onset time for motor blockade
  • Produce prolonged sensory blockade
  • Produce prolonged motor blockade
  • Produce prolonged postoperative analgesia
  • Produce sedation in which patients were asleep and easily arousable.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kanazi GE, Aouad MT, Jabbour-Khoury SI, Al Jazzar MD, Alameddine MM, Al-Yaman R, et al. Effect of low-dose dexmedetomidine or clonidine on the characteristics of bupivacaine spinal block. Acta Anaesthesiol Scand 2006;50:222-7.  Back to cited text no. 1
    
2.
Milne B, Cervenko FW, Jhamandas K, Sutak M. Intrathecal clonidine: Analgesia and effect on opiate withdrawal in the rat. Anesthesiology 1985;62:34-8.  Back to cited text no. 2
    
3.
Coombs DW, Saunders RL, Fratkin JD, Jensen LE, Murphy CA. Continuous intrathecal hydromorphone and clonidine for intractable cancer pain. J Neurosurg 1986;64:890-4.  Back to cited text no. 3
    
4.
Niemi L. Effects of intrathecal clonidine on duration of bupivacaine spinal anaesthesia, haemodynamics, and postoperative analgesia in patients undergoing knee arthroscopy. Acta Anaesthesiol Scand 1994;38:724-8.  Back to cited text no. 4
    
5.
Benhamou D, Thorin D, Brichant JF, Dailland P, Milon D, Schneider M. Intrathecal clonidine and fentanyl with hyperbaric bupivacaine improves analgesia during cesarean section. Anesth Analg 1998;87:609-13.  Back to cited text no. 5
    
6.
Chiari A, Lorber C, Eisenach JC, Wildling E, Krenn C, Zavrsky A, et al. Analgesic and hemodynamic effects of intrathecal clonidine as the sole analgesic agent during first stage of labor: A dose-response study. Anesthesiology 1999;91:388-96.  Back to cited text no. 6
    
7.
Uhle EI, Becker R, Gatscher S, Bertalanffy H. Continuous intrathecal clonidine administration for the treatment of neuropathic pain. Stereotact Funct Neurosurg 2000;75:167-75.  Back to cited text no. 7
    
8.
Julião MC, Lauretti GR. Low-dose intrathecal clonidine combined with sufentanil as analgesic drugs in abdominal gynecological surgery. J Clin Anesth 2000;12:357-62.  Back to cited text no. 8
    
9.
Santiveri X, Arxer A, Plaja I, Metje MT, Martínez B, Villalonga A, et al. Anaesthetic and postoperative analgesic effects of spinal clonidine as an additive to prilocaine in the transurethral resection of urinary bladder tumours. Eur J Anaesthesiol 2002;19:589-93.  Back to cited text no. 9
    
10.
Sites BD, Beach M, Biggs R, Rohan C, Wiley C, Rassias A. Intrathecal clonidine added to a bupivacaine-morphine spinal anesthetic improves postoperative analgesia for total knee arthroplasty. Anesth Analg 2003;96:1083-8.  Back to cited text no. 10
    
11.
Baker A, Klimscha W, Eisenach JC, Li XH, Wildling E, Menth-Chiari WA, et al. Intrathecal clonidine for postoperative analgesia in elderly patients: The influence of Bari city on hemodynamic and analgesic effects. Anesth Analg 2004;99:128-34.  Back to cited text no. 11
    
12.
Förster JG, Rosenberg PH. Small dose of clonidine mixed with low-dose ropivacaine and fentanyl for epidural analgesia after total knee arthroplasty. Br J Anaesth 2004;93:670-7.  Back to cited text no. 12
    
13.
Paech MJ, Pavy TJ, Orlikowski CE, Yeo ST, Banks SL, Evans SF. Postcesarean analgesia with spinal morphine, clonidine, or their combination. Anesth Analg 2004;98:1460-6.  Back to cited text no. 13
    
14.
Strebel S, Gurzeler JA, Schneider MC, Aeschbach A, Kindler CH. Small-dose intrathecal clonidine and isobaric bupivacaine for orthopedic surgery: A dose-response study. Anesth Analg 2004;99:1231-8.  Back to cited text no. 14
    
15.
van Tuijl I, van Klei WA, van der Werff DB, Kalkman CJ. The effect of addition of intrathecal clonidine to hyperbaric bupivacaine on postoperative pain and morphine requirements after caesarean section: A randomized controlled trial. Br J Anaesth 2006;97:365-70.  Back to cited text no. 15
    
16.
Sethi BS, Samuel M, Sreevastava S. Efficacy of analgesic effects of low dose intrathecal clonidine as an adjuvant to bupivacaine. Indian J Anaesth 2007;51:415-9.  Back to cited text no. 16
  [Full text]  
17.
van Tuijl I, Giezeman MJ, Braithwaite SA, Hennis PJ, Kalkman CJ, van Klei WA. Intrathecal low-dose hyperbaric bupivacaine-clonidine combination in outpatient knee arthroscopy: A randomized controlled trial. Acta Anaesthesiol Scand 2008;52:343-9.  Back to cited text no. 17
    
18.
Andrieu G, Roth B, Ousmane L, Castaner M, Petillot P, Vallet B, et al. The efficacy of intrathecal morphine with or without clonidine for postoperative analgesia after radical prostatectomy. Anesth Analg 2009;108:1954-7.  Back to cited text no. 18
    
19.
Al-Mustafa MM, Abu-Halaweh SA, Aloweidi AS, Murshidi MM, Ammari BA, Awwad ZM, et al. Effect of dexmedetomidine added to spinal bupivacaine for urological procedures. Saudi Med J 2009;30:365-70.  Back to cited text no. 19
    
20.
Al-Ghanem SM, Massad IM, Al-Mustafa MM, Al-Zaben KR, Qudaisat IY, Qatawneh AM, et al. Effect of adding dexmedetomidine versus fentanyl to intrathecal bupivacaine on spinal block characteristics in gynaecological procedures: A double blind controlled study. Am J Appl Sci 2009;6:882-7.  Back to cited text no. 20
    
21.
Saxena H, Singh SK, Ghildiyal S. Low dose intrathecal clonidine with improves onset and duration of block with haemodynamic stability. Internet J Anaesthesiol 2010;23:1.  Back to cited text no. 21
    
22.
Gupta R, Bogra J, Verma R, Kohli M, Kushwaha JK, Kumar S. Dexmedetomidine as an intrathecal adjuvant for postoperative analgesia. Indian J Anaesth 2011;55:347-51.  Back to cited text no. 22
[PUBMED]  [Full text]  
23.
Shukla D, Verma A, Agarwal A, Pandey HD, Tyagi C. Comparative study of intrathecal dexmedetomidine with intrathecal magnesium sulfate used as adjuvants to bupivacaine. J Anaesthesiol Clin Pharmacol 2011;27:495-9.  Back to cited text no. 23
[PUBMED]  [Full text]  
24.
Jain D, Khan RM, Kumar D, Kumar N. Perioperative effect of epidural dexmedetomidine with intrathecal bupivacaine on haemodynamic parameters and quality of analgesia. South Afr J Anaesth Analg 2012;18:105-9.  Back to cited text no. 24
    
25.
Shah A, Patel I, Gandhi R. Haemodynamic effect of intrathecal dexmedetomidine added to ropivacaine intraoperatively and for postoperative analgesia. Int J Basic Clin Pharmacol 2013;2:26-9.  Back to cited text no. 25
    
26.
Abdelhamid SA, El-Lakany MH. Intrathecal dexmedetomidine: Useful or not? J Anesth Clin Res 2013;4:351.  Back to cited text no. 26
    
27.
Jamliya RH, Deshmukh V, Rajesh C, Maliwad J, Shah BJ, et al. Effect of adding dexmedatomidine in intrathecal bupivacaine versus intrathecal bupivacaine alone on spinal block characteristics in orthopaedic lower limb procedures. Res J Pharm Biol Chem Sci 2013;4:1340-6.  Back to cited text no. 27
    
28.
Joshi R, Mori J, Mehta KA. Effect of intrathecal dexmedetomidine bupivacaine combination on duration of subarachnoid block and post operative analgesia. Int J Sci Res 2013;2:288-9.  Back to cited text no. 28
    
29.
Chhabra AR, Jagtap SR, Dawoodi SF. Comparison of clonidine versus fentanyl as an adjuvant to intrathecal ropivacaine for major lower limb surgeries: A randomized double-blind prospective study. Indian J Pain 2013;27:170-4.  Back to cited text no. 29
  [Full text]  


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Materials and Me...
Observation and ...
Discussion
Conclusion
References
Article Figures

 Article Access Statistics
    Viewed71    
    Printed2    
    Emailed0    
    PDF Downloaded22    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]